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Abstract

Enhancing professionalism is an important goal of all physicians, both as individuals and as members of educational and institutional communities of practice. Despite a great deal of dialogue and discourse, the medical profession struggles to ensure that all physicians are able to embrace and live the values of professionalism, notwithstanding the myriad stressors present in today's evolving health care environment. The authors suggest a move beyond the traditional educational paradigms focused on reinforcing rules, providing role models, rewarding right behavior, and removing those who falter, and that we instead view the problem of professionalism as a complex adaptive challenge requiring new learning. Approaching lapses in professionalism as a form of medical error may provide a fresh outlook and may lead to the development of successful strategies to help physicians realize their commitment to the values of professionalism, despite the inevitable challenges that arise throughout their careers.

Over the past two decades, the topic of professionalism has occupied the time and intellect of many thoughtful scholars.1–6 Such interest reflects a passionate desire to reconnect with the core values, practices, and behaviors that physicians and patients see as exemplifying the very best of what medicine should be in the face of the increasing commercialization of medicine. Scholarly publications delineate the norms and behaviors of professionalism,7 document shortcomings in the practice and pedagogy of professionalism,8 and discuss the moral and ethical underpinnings of the concept of professionalism.5,9 Specific targeted interventions have been designed with the overarching goal of promoting professional behavior and reducing unprofessional conduct. These include new covenants,10 curricula,11,12 assessment strategies,13,14 and intervention programs15 and programs for redesigning institutional culture.16

Despite these efforts, breaches of professionalism occur at every medical center every day. Some of these incidents make their way into the public arena, but many go unreported. They range from a physician speaking disrespectfully to a patient or colleague to conflicts of interest with the pharmaceutical industry to outright fraud. Indeed, medicine seems to have a professionalism problem that is widespread and concerning, to say the least, and we struggle mightily with how to deal with it.

What are we going to do about our professionalism problem? How do we restore, reinforce, and sustain medical professionalism and regain the public trust in a time of rapid societal change and marked turbulence in the health care industry? Despite the explosion of articles on these topics, the path to take is unclear.

In this article, we propose a different approach to understanding and tackling the professionalism problem. Although we commend the solutions that have been implemented to date—and have ourselves incorporated several of them—we believe that a fresh approach is needed. To start, we must reframe the problem. Professionalism, as we see it, has to date been tackled largely as a technical or simple problem. As a consequence, most of the solutions that have been implemented have been technical and mechanical—an approach that, we believe, is a limited and insufficient line of attack. We believe that medicine's problems with professionalism are far more complicated and convoluted than previously recognized and that they are best approached as what has been described as an adaptive challenge or complex learning problem.17,18

Contrasting Simple Problems and Complex Problems

Problems are problems because they represent a gap between a current reality and a desired future. Whether personal or professional, problems can be arbitrarily categorized as simple (technical) or complex (adaptive). Simple problems are relatively easy to recognize, and those involved in solving the problem have a common understanding of the issues. Solutions are technical: They are logistically straightforward, and they come from existing knowledge that is applied within a conventional framework. Success can be achieved relatively quickly. Once the problem is fixed, it tends to stay fixed without further intervention. An almost absurd example of a simple problem would be a faucet that leaks because of a defective or worn-out rubber washer. The problem can be described and made sense of in the same way by almost anyone. Changing the rubber washer closes the gap between the current reality (the faucet is constantly dripping when it is turned off) and the desired future (the faucet no longer leaks when it is shut off). The problem stays fixed until the washer wears out, and then the same solution can again be successfully employed. No controversy exists; no new knowledge must be generated to solve the problem; no strategies must be reconfigured.

Complex, adaptive challenges exist when there is disagreement about the nature of the problem, the desired future state, and the steps required to narrow the gap between the present and the future. They can be viewed as complex learning problems, because they are difficult to understand and manage. Strategies for solving complex, adaptive challenges are outside the standard repertoire of the organization or the individual, and, as such, they require the generation of new knowledge. The execution of each strategy is subject to unpredictable variables, strong emotions, and external forces and thus necessitates continuous learning and adaptation. Required changes in processes, behaviors, and attitudes may be painful. The work involved in solving adaptive changes is arduous and almost never completely finished.17,19

Consider the faculty member who consistently speaks disrespectfully to his subordinates. His department chair will most likely attempt to solve this problem by using standard interventions, such as reminders about institutional policies, or sanctions, such as the loss of privileges. These technical solutions may be necessary. But only when the faculty member in question makes the necessary life changes—confronting the issues that lead to his demeaning behavior—will his problem be solved. His problem is a complex one; it is an adaptive challenge, and technical solutions are inadequate.

This faculty member has to learn to be respectful, and this process is not simply a matter of adhering to rules. Rather, it is a matter of learning a new identity, of seeing himself differently—first, as a person who needs to be in control of his outbursts and, then, as a person who can relate to others without being disrespectful. For faculty members who exhibit deeply ingrained unprofessional behaviors, making this change can be quite a complex learning problem.

Many of the challenges that confront our academic medical centers today are adaptive challenges.20 The solutions that many academic medical centers apply to many of these challenges tend to be technical, such as developing rules and regulations or demanding more resources. But enforcing rules and throwing resources at an adaptive challenge won't solve the underlying problem, although those steps might temporarily mitigate the symptoms. The solution generally requires changes in the individual and in the shared mental models, values, and beliefs of the institution. Learning that leads to a new way of thinking and a subsequent change in behavior almost invariably requires a period of uncomfortable adjustment for all involved.

Tackling Medicine's Problem of Professionalism

Clarifying and closing the gap between aspirations and reality

Tackling the problem of professionalism as a complex adaptive challenge begins with developing a shared vision (the desired future state) and a shared understanding of the problem (the current reality). The solution to the problem begins there because, as with all adaptive challenges, there is considerable disagreement about what a culture of professionalism should look like and how much of a professionalism problem exists today.

Medical professionalism is a set of core beliefs and values that guide the daily work of physicians who are serving patients. At critical junctures throughout history, medical leaders have set forth treatises on the topic of professionalism with the intent of creating a shared vision for the profession. The Hippocratic Oath attempted to distance true physicians from the charlatans in ancient Greece. Thomas Percival, reacting to self-serving behavior on the part of physicians during a Manchester, England, epidemic in the late 1700s, wrote the first modern code of medical ethics.21 More recently, the American Board of Internal Medicine Foundation joined with the American College of Physicians–American Society of Internal Medicine and the European Federation of Internal Medicine in responding to widespread concerns that changes in health care delivery and practice were threatening the nature of professionalism by publishing a charter on professionalism,10 designed to unite the profession around a specific set of idealized principles and commitments (List 1). Several other organizations have weighed in on the expected values and virtues of physicians, each viewing the problem from a different vantage point.7,22,23

The nature of the current reality of medical professionalism is also in need of clarification. Controversy exists about whether the problem with professionalism represents the aberrant behavior of a few bad physicians or a more insidious and pervasive shift in the attitudes of many. The lay press have disseminated multiple detailed reports of egregious examples of unprofessional behavior on the part of practicing physicians. Highly publicized examples of both research- and practice-based conflicts of interest on the part of physicians, tolerance of clearly incompetent physicians, resistance to adopting evidence-based measures to prevent errors and improve care, and acceptance of escalating health care expenditures without a parallel increase in quality or decrease in health disparities have left the public with a view of medical professionalism as representing a set of guild-protected privileges rather than a lofty moral covenant. Whereas professional organizations representing physicians believe that medical professionalism is in need of improvement, the views of individual physicians are less clear. The study of practicing physicians by Campbell and colleagues24 documents that, although practicing physicians accept the “rules” of professionalism, their behaviors may differ. Physicians believe that they themselves consistently embrace and live values of professionalism, but they are more than willing to acknowledge the shortcomings of their peers.25 Mizrahi26 observed three “collectively acquired maladaptive defense mechanisms” common to physicians confronted with shortcomings in their performance: denial (it wasn't really a lapse, just a different style), discounting (he did yell at that nurse, but she had it coming), and distancing (it was a mistake, but we are all human).

In summary, there continue to be disagreements about how serious and widespread medicine's problem with professionalism is and about what we are willing to do to solve the problem. Further dialogue is essential: If we are to develop a collective understanding of the challenges, we must confront those challenges and be able to craft a shared vision of the kind of future we wish to create.

Challenging deeply ingrained assumptions and values

One of the most wrenching aspects of tackling all adaptive challenges is the need to question our long-standing entrenched beliefs and assumptions. As noted by Heifetz and Linsky,17 adaptive work is required when our deeply held beliefs are challenged, when the values that made us successful become less relevant, and when legitimate, yet competing, perspectives emerge. The losses often involve learning to modify loyalties and develop new competencies. Part of the learning will require distinguishing, among all that is valued, what must be carried forward and what is expendable. Accepting these changes will involve loss and fear.17

Renewing our commitment to professionalism will require that people change. When we ask people to change, we are asking them to suffer the loss of long-standing worldviews and habitual ways of doing things. This type of change is far from easy. The internist who has learned to yell at housestaff who call in the middle of the night has to retrain herself to be calm; this is a painful process that involves unlearning (letting go). The faculty member who has to terminate his relationship with the drug company that, for years, has reimbursed him handsomely will experience loss. He may worry about making ends meet when this relationship ends. As noted by Peter Senge, “Learning that changes mental models is immensely challenging. It is disorienting. It can be frightening as we confront cherished beliefs and assumptions. It cannot be done alone. It can occur only within a community of learners.”19

The most deeply seated assumption about professionalism is that it is an attitudinal competency, based predominantly on immutable character traits present at the time of entrance into medical school. Like other moral characteristics, professionalism is often believed to be a dichotomous competency, presumed to be fully present until it is proven, by the observation of a lapse, to be absent. This mental model has constrained our discussion about the nature of professionalism, our ability to affect the development of professionalism in our trainees, and our approach to lapses in professionalism.

The assumption that the capacity to be professional is fixed in an individual's character at the time of entrance into medical school has led investigators to search for the perfect process for selecting the ideal medical students.27,28 Unfortunately, no selection strategy has had more than a minor impact on our ability to predict performance in the clinical arena. As noted by Leach,29 whereas adult learners may enter medical school with the desire to exhibit the values of professionalism, they have no experience in maintaining professional behavior under the challenging circumstances that confront practicing physicians. Behaving professionally often requires individuals to ignore the powerful deficit needs (for shelter, food, sleep, and safety) that generally dictate personal decision making.30 It is impossible to predict whether someone will be capable of behaving in a way that defies human instinct until that person has been observed in stressful situations in which this counterintuitive response can be practiced. Context in decisions about professional behavior is increasingly recognized as critically important.31–34

As a consequence of our assumption that professionalism is a largely attitudinal competency, we have restricted our teaching methods to providing rules and role models.3 Unfortunately, studies have shown that practicing physicians do not agree on the rules governing behavior in different professionally challenging situations; nor are they internally consistent in the application of rules they espouse.35 The difference between the rules and values articulated in the classroom and the behaviors modeled in the clinical setting has been termed the “hidden curriculum.”36,37 This disconnect is, in itself, antithetical to the concept of integrity, and it has been blamed for the increasing cynicism seen in medical students as they move through medical school.38 Huddle39 relates this difference between values and actions to the Greek concept of akrasia, or weakness of will; however, the situation may be even more complex than acknowledging the frailties of the human spirit.

Uncertainty about whether professionalism can be taught has led to an overemphasis on the process of evaluation of professionalism. We are, in essence, saying, “If I can't teach them to be professional, at least I can find those who aren't professional, and deal with them.” Because there are no universally accepted tools other than counseling to help those about whom reports of unprofessional behavior surface, this focus on evaluation breeds fear in students who are concerned that honest mistakes in managing complex situations may lead to a label of “unprofessional.”40,41 Concern that the authorities who receive reports of a lapse will either underreact (do nothing) or overreact (punish severely) may contribute to the reluctance of faculty to accurately report lapses.42

The people with the problem are the problem … and the solution

Despite the fact that the most widely disseminated anecdotes about unprofessional behavior have practicing physicians as their subjects, most physicians and physicians' organizations have chosen to look upstream, to the educational process, to fix the problems with professionalism. There are rational, emotional, and pragmatic reasons for assigning the responsibility for solving the problem to the current generation of trainees and their teachers. Evidence suggests that problems with professionalism may start in medical school.43,44 Physicians who were the subjects of more than one complaint about their professional behavior during medical school have been found more likely to be sanctioned by state medical boards at some point during their career.45 It is emotionally difficult to reconcile our view of ourselves as members of an honored profession with the concerns that have been raised. It is more comfortable to assume that something is different about the current generation of people entering into the profession. The strongest stimulus for focusing on the educational system may be pragmatism. It seems easier to change the controlled environment of 129 medical schools than to change the behavior of one million independent physicians. It may be easier and safer to target students or their teachers, but the problem with professionalism cannot be solved until all who create the social culture in which we practice share responsibility for tackling the problem.

Future Needs

The need for new learning

Learning from an adaptive challenge requires that we look at the problem through a new lens. Reframing our goal from identifying the perfect physician candidate to developing physicians who remain professional despite stressors and competing professional priorities changes the discussion and opens our minds to new possibilities.

The new learning challenge is to understand the nature of the challenges of professionalism and of the skills exhibited by those physicians who remain professional despite challenges. Similarities exist between lapses in professionalism and medical errors. Key concepts about errors in medicine also are intuitively true about lapses in professionalism.46 Like medical errors, lapses in professionalism are likely to be more common than we suspect, because only those that are egregious come to the attention of authorities.24,47 Their impact on patients ranges from negligible (an attending physician's request to receive continuing medical education credit for grand rounds she didn't attend) to potentially life-threatening (a resident physician's decision to leave the hospital before he checks the postprocedure chest radiograph). Lapses in professionalism can be committed by good physicians who are temporarily unable to handle the situation at hand but who are, over the course of a career, still considered to act professionally. Finally, systems decisions such as staffing, duty hours restrictions, bureaucratic procedures, and reimbursement strategies may precipitate a lapse.

Tools used to understand the causes of medical errors can also help us understand lapses in professionalism. A blame-free environment, in which people are encouraged to report lapses and near misses, may help us understand the spectrum of challenges to professionalism and the maladaptive responses to these challenges. Root cause analysis can then be used to systematically answer the “why” of lapses in professionalism. The concepts of active errors (those that are the direct result of deficiencies in knowledge, judgment, or skill on the part of physicians) and latent errors (lapses resulting from systems policies and procedures that either fail to prevent a lapse or fail to mitigate its impact on a patient) are also useful in developing targeted strategies for education and prevention.46

Root cause analysis of lapses in professionalism at our institution and in the literature reveals common themes. Challenges to professionalism can result from values conflicts (e.g., upholding one professional value requires the subjugation of another),31 patient conflicts (upholding commitments to one patient means delaying or denying a similar commitment to another), Maslow conflicts (upholding a professional value is difficult because of unmet deficit needs),30 or systems conflicts (adhering to laws, rules, policies, and procedures may be contrary to professional values).4,48,49 Examples are shown in Table 1.

Indeed, most lapses in professionalism are not the result of a deficiency in knowledge; the rules and values are clear. Instead, most lapses represent deficiencies in judgment and skill. They occur when the physician in question fails to recognize the presence of a challenge to professionalism or lacks the skills to handle a challenge at the time it occurs. Professional action in these circumstances does not require rule-based action but requires thoughtful analysis and judgment.33 This observation support's Leach's29 construct, drawn from the earlier work of Dreyfus and Dreyfus,30 that professional behavior is a skill set that follows the same developmental curve, from beginning through competent to expert, an idea that the earlier authors articulated for other competencies. It is thus logical to assume that professionalism can be enhanced by coaching and deliberate practice, rather than by the technical solutions of enforcement and reminders.50

The need for experimentation and resilience

How do we train physicians who are “habitually faithful to professional values in highly complex situations”?29 When lapses in professionalism are viewed as deficiencies in judgment or skills, rather than as an attitudinal deficiency or a character flaw, educational solutions become readily available and emotionally acceptable. We propose that educational and institutional leaders join together to experiment with a new mental model of professionalism, based on a set of six assumptions (Table 2).

Assumption 1.

Professionalism is a multidimensional competency with attitudinal and knowledge- and skill-based components. The commitment to understanding and accepting the rules of professionalism that often is evident in the incoming medical student should be considered the novice stage of professionalism. Progression from novice to expert requires that the individual develop a sophisticated set of skills that enable him or her to instantly recognize and intuitively meet increasingly complex professional challenges. This development will require experiential learning, structured reflection, and coaching by faculty and trusted colleagues.

Assumption 2.

Education about professionalism should begin with the assumptions that remaining true to professional values is difficult at times and that lapses are common. Physicians obtain certification in advanced cardiac life support so that they can respond quickly and appropriately to predictable medical crises. We must identify educational strategies that help physicians build a similar repertoire of responses to deal with predictable challenges to professionalism. Principles of emotional intelligence, reflective practice, and mindfulness can be applied to enhance professionalism skills, as outlined in Table 3.51–53

Assumption 3.

The appropriate response to a lapse in professionalism is to engage the individual in a structured root cause analysis of the lapse. This objective approach can identify solutions that target the true cause of the lapse.32,54,55 The appropriate response to a student who misjudges a complex situation while under great emotional stress should be to coach the student to competence rather than to label him or her as unprofessional. In contrast, disciplinary action may still be appropriate for novices who cannot meet even simple challenges to professionalism and for physicians who, despite a supportive environment, show a consistent disregard for established standards.

Assumption 4.

The system plays a role in the extent to which physicians remain true to professional values. Poor decisions about staffing models and reimbursement strategies may pose unnecessary challenges to professional behavior. Physician leaders should work to reshape the health care system to facilitate professional behavior. Locally and nationally, the profession must proactively work with administrators in health systems to ensure that policies and procedures governing reimbursement and reward are supportive of professional values.48 We need to recognize the human element of professional behavior and find opportunities to reconfigure health care systems to support reflection, personal well-being, and professional renewal. Improving clinical role modeling by championing positive examples of professionalism can result in significant culture change.16

Assumption 5.

Professionalism is a dynamic competency. Although the values of professionalism remain true over time, the challenges to professional behavior may change as a result of trends in the biomedical, social, political, and economic environments of health care. Physicians should understand the need for continuous education in professionalism as a core component of continuing medical education and maintenance of certification.

Assumption 6.

The educational system begins the process of professional development for physicians, but it is the community of practicing physicians, health care leaders, and educators who must accept responsibility for maintaining professionalism. Everyone in the medical profession should be willing and able to initiate and participate in conversations about professionalism. We should assume that our peers want to be professional and that they will welcome interventions from a trusted colleague when circumstances suggest that a lapse is imminent. We need to prepare physicians in leadership roles to lead ongoing discussions with their community of professionals about how to deal compassionately but firmly and consistently with those physicians who, despite our best efforts, continue to behave in ways that are antithetical to our values. As in the patient safety movement, the right balance between physician accountability and systems emphasis must be sought.56

Final Thoughts

To quote William Osler,57 “You are in this profession as a calling, not as a business; as a calling which extracts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow man. We must work in the missionary spirit with a breadth of charity that raises you far above the petty jealousies of life.”

Enhancing medical professionalism will require approaching the need for its improvement as a complex adaptive challenge rather than as a technical problem. As such, new learning and sustained, arduous work will be required to propose and enact successful solutions. Progress can be made with discussions that emphasize the fallibility of humans, the individual and collective responsibility of all physicians to accept the work required to sustain the values we espouse, and the importance of supportive cultures monitored for their impact on professionalism, as well as by continuous learning and improvement by all.

7Association of American Medical Colleges; National Board of Medical Examiners. Embedding Professionalism in Medical Education: Assessment as a Tool for Implementation. Available at: http://www.nbme.org/PDF/NBME_AAMC_ProfessReport.pdf. Accessed March 1, 2010.

10ABIM Foundation; American Board of Internal Medicine; ACP-ASIM Foundation; American College of Physicians–American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002;136:243–246.

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